CPThyroidectomy

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Patients info label here
Thyroidectomy
Nr.
Nursing Diagnosis
Deficient knowledge: Preoperative
Date
Nursing Intervention/s and tasks
Teaching: Preoperative
Related factors:
Unfamiliarity with disease and treatment
Symptoms / Risk factors:
Increase in anxiety level
Multiple questions
Outcome / Goal:
Patient verbalize understanding of procedure
Describe the preoperative routines
Anxiety
Anxiety reduction
Related factors:
Threat to or change in Health status
Symptoms / Risk factors:
Anxious
Assess reasons for anxiety
Restlessness
Outcome / Goal:
Will experience a reduction in anxiety
Determine the patient's expectations of the surgery
Provide time for the patient to ask questions and discuss concerns
Assess voice and facial movements for comparison after surgery
Check lab test - serum calcium level
Reduce unnecessary externa stimuli
Spend time talking with patient. Allow to express feelings
Calming Technique
Maintain calm, deliberate manner
Reassure patient of personal safety or security
Acute pain
Pain Management
Related factors:
incision
Symptoms / Risk factors:
Facial mask
Verbal or coded report
Outcome / Goal:
Patient appears relaxed and comfortable
Patient verbalizes relief of pain
Asses cause of pain
Risk for injury
Neurologic Monitoring
Related factors:
Incision
Recurrent laryngeal nerve damage
Symptoms / Risk factors:
Breathing difficulties
Inability to speak
Aphonia
Outcome / Goal:
No sign of speaking /breathing difficulties
Assess symptoms of breathing/ speaking difficulties
Impaired skin integrity
Incision Site Care
Related factors:
surgical procedure
Symptoms / Risk factors:
surgcial wound
bleeding
Outcome / Goal:
surgcial wound clean
Obs dressing (bleeding)
Risk for imbalanced fluid volume
Fluid Monitoring
Related factors:
Nausa
Symptoms / Risk factors:
Fluid intake low
Outcome / Goal:
Maintain adequate fluid balance while hospitalized
Obs fluid balance (inntake and out)
Administer medication as prescribet
Administer O2 as orderd
Obs. pain (effectivnes of medication)
Optimize the patient's comfort in bed
Obs. signs of infection
Change dressing as prescribet
Obs fluid balance __________________ 24 hour
Obs vital signs Bp. O2 and pulse
(Plan continues on the next page)
1
Sign.
Patients info label here
Thyroidectomy
Nr.
Nursing Diagnosis
Deficient knowledge: Postoperative
Related factors:
Lack of previous experience with surgery
Symptoms / Risk factors:
Questions
Outcome / Goal:
Patient verbalizes understanding of need for follow-up care
Plan created:12.11.2016
Date
Nursing Intervention/s and tasks
Discharge Planning
Discuss with physician the discharge plan and obtain orders if needed
Involve the patient/family in the discharge process
Dscharge planned _________
Wound Care
Teach the patient / caregiver about wound care using aseptic technique
by:_________________________________________
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